To identify of signs and symptoms of infectious diseases through screening and assessment To understand the rationale for regular screening for infectious diseases To describe appropriate care plans which include prevention and treatment for both substance misuse and infection ID: 918830
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Slide1
March 2016
INFECTIOUS DISEASES
Slide2To identify of signs and symptoms of infectious diseases through screening and assessment To understand the rationale for regular screening for infectious diseases
To describe appropriate care plans which include prevention and treatment for both substance misuse and infectionLEARNING OUTCOMES
Slide3Substance misuse is associated with infectious diseasesLevels of infection in injecting substance misusers is high
ie ~ 50%Life style and mode of use of substances are the main ‘causes’Substances can predispose to infection by lowering immunity or specific local effectsInfectious disease risk is related to the mode of use rather than specific substancesAssessment of drug users for risk behaviour and infectious diseases
CONTEXT
Slide4Hepatitis B and C are major causes of liver disease and liver cancer20-25% of people with chronic hepatitis B have progressive liver disease which leads to cirrhosis in some cases
Over 90% people with hepatitis C have a history of injecting15-20% people with hepatitis C will develop liver cirrhosis after 20 years and 5% of those will develop liver cancerHepatitis C is the commonest indication for transplantation214000 are chronically infected with hepatitis C 2.2% of all people being seen for care in the UK have HIV
Slide5Individuals put themselves at risk due to chaotic lifestyle and effect of substancesDrug users who are having sex without protection and sharing injecting equipment or
paraphenalia are at risk of contracting BBV (blood borne viruses eg hepatitis B and C, and HIV)Patients who misuse substances are likely to be susceptible to tuberculosis (TB)Drinking alcohol – especially binge drinking – and ‘club drugs’ alter judgement and impair decisions about sex and other drug use, leading to unprotected sex and sharing of injecting equipment
DISTINCTIVE FEATURES
Slide6Substance misusers may view BBV as ‘occupational’ hazards of drug use Drug users may not recognise or differentiate the symptoms of BBV from intoxication, withdrawal or poor self care
Drug users may think the symptoms derive from impurities in street drugsPatients may present late to services and be less compliant with the medication prescribedBARRIERS TO DETECTION
Slide7Infections may be viral, acute bacterial and sexually transmittedHistory taking should elicit information about behaviours that may have put the patient at risk
Injecting, unprotected sex and receiving a blood transfusion in other countriesInformation about those with whom the patients has had intimate or prolonged contactContact tracing may need to take placeASSESSMENT
Slide8Common where water supplies and sewage disposal are poorPersonal and food hygiene are poor
Living in poor conditions, in crowded accommodation where this is no running water or adequate sewage eg hostels, squatsBlood to blood spread through needle sharing Transmission is by fecal and oral routesSymptoms may last for a week or more and include: flu type symptoms, nausea, stomach ache and diarrhoea, jaundice
HEPATITIS A
Slide9Hepatitis B causes liver inflammation and fibrosisUntreated can lead to cirrhosis and liver failure or hepatocellular cancer
2% cause chronic hepatitisInformation about initiation of injecting, sharing of injecting equipment, frequency of sharing, number and type of contacts who may have been injectingHepatitis B is notifiable to Public health EnglandTransmission is by injecting, sexual contact and mother to babyHEPATITIS B
Slide10A mild flu like feverTirednessAching limbs or joints
Loss of appetiteFeeling sick or vomitingReluctance to drink alcohol or smokeJaundice, itchy skin and dark urineHEPATITIS B - SYMPTOMS
Slide11Many individuals with hepatitis C are abusing alcohol 50% lead to cirrhosis, chronic hepatitis and hepatocellular cancer
Transmission is via injecting, sexual contact, mother to child at birthIn 40% cases infected individuals cannot identify a source for their infectionCocaine can damage the inside of the noe leading to bleeding Inhalation of contaminated blood may lead to infectionSharing items eg toothbrushes, razors, scissors and blood products may spread infection
No vaccine is availableHEPATITIS C
Slide12Flu like symptomsMild to severe fatigue
AnxietyWeight lossLoss if appetiteInability to tolerate alcoholDiscomfort over liver areaProblems with concentrationNauseaJaundice
HEPATITIS C - SIGNS AND SYMPTOMS
Slide13Antibody test – proteins made by the body to respond to the virusPolymerase chain reaction (PCR) or viral RNA tests – identify the presence of the virus
Liver function test to identify the impact on the liverLiver biopsy to assess severity of damage from chronic hepatitis CHEPATITIS C - TESTS
Slide14Flu like illness a few weeks after infection with HIV – 80% casesSymptoms indicate that the body is responding to the infection
Symptoms are non-specific History should try to establish risks associated with unprotected sex, sex with bisexual men, sharing injecting equipment or paraphernaliaTransmission is via injecting, sexual contact, blood including menstrual blood, mother to baby before during or after birth during breast feedingHIV cannot be transmitted through saliva, sweat, tears, feces and urine
HUMAN IMMUNODEFICIENCY VIRUS (HIV)
Slide15FeverSore throatBody rash
TirednessJoint painMuscle painSwollen glandsTests on blood are very reliable and provide a result from 4 weeks after possible infectionTreatment is very successful with anti retroviral treatment
HIV – SYMPTOMS, TESTS AND TREATMENT
Slide16Transmission is via injectionStaphylococcus and streptococcus are the agentsEndocarditis – fever, heart murmur, peripheral stigmata
Necrotising fasciitis – pain out of proportion with clinical findingsBotulism: scratchy throat, cranial nerve palsies and paralysisANTIBACTERIAL INFECTION
Slide17Risk factors include:Smoking cigarettes, other serious illnesses (hear disease, liver cirrhosis), immune system problems (cancer treatment, HIV/AIDS, organ transplant)
Symptoms: FeverCough with yellow, green or blood tinged mucousChest pain the worsens when coughing or breathingSudden onset of chillsHeadache and muscle painsRESPIRATORY INFECTIONS - PNEUMONIA
Slide18Food, saliva, liquids or vomit is breathed into the lungs or airways after alcohol consumption or overdoseSymptoms include: bluish skin discolouration
Chest painCoughing up foul smelling sputum FatigueFeverShortness of breathWheezingExcessive sweting
ASPIRATION PNEUMONIA
Slide19Listen for abnormal chest soundsTake blood sample to get a white cell count. A high count usually indicates infection
Take blood or mucous samples to identify infection causing pathogenOrder chest x rays to confirm the presence and extent of infectionASPIRATION PNEUMONIA - DIAGNOSIS
Slide20Early detection makes it easier to treat with antibiotic combination therapy for 6 months: drug users might find compliance a problem
Signs and symptoms include: persistent feverHeavy sweating at nightLoss of appetiteUnexplained weight lossGeneral and unusual sense of tirednessHaemoptysisRecent contact with someone who has TB
TUBERCULOSIS
Slide21Frequently asymptomaticNeed regular screening for detectionAll associated with morbidity if left untreated
SyphylisChlamydiaGonorrhoeaHPV – human papilloma virusSEXUALLY TRANSMITTED DISEASES
Slide22Vaccine is availableConsider single dose or combined vaccine – depends on whether the patient is likely to return for a subsequent dose
One dose of single vaccine confers greater protection against Hep A than one dose of the combined Hep A Hep B vaccine Vaccinate all injecting drug users against Hep ASingle component preferable to combined Hep A and Hep B vaccineFor single vaccine give 2 doses with second dose after 6-12 monthsSecond dose may be delayed for up to 3 years
TREATMENT – HEPATITIS A
Slide23Most people with acute hepatitis recover without treatment within 4-12 weeks2% cause chronic hepatitis which can lead to cirrhosis and hepatocellular cancer
Can be treated with antiretroviral drugsA vaccine is availableVaccinate all drug users against Hepatitis B – non-injectors may become injectorsHEPATITIS B
Slide24No need to carry out pre vaccination testingUse accelerated 0, 7 and 21 day schedule to aim to complete the course quickly.
Incomplete vaccination offers some protection but completing the course is recommendedOffer vaccination to partners and childrenHEPATITIS B
Slide25Treatment can eradicate infection in 40-80% of infected individualsAntiviral treatment consists of self administered weekly subcutaneous injections of pegylated interferon and twice daily oral ribavirin for 24-48 weeks
No vaccine is availableSubstance misusers will need to persevere as treatment is intensiveThey need to be detoxified or stable on substitute medication and abstinent from other drugsInjecting the antiviral medication may lead to relapse to (injecting) drug use
HEPATITIS C
Slide26If patients continue to drink while taking medication there is a high risk of liver damageRegular blood tests required to check on liver function
Patients with HIV or hepatitis will need regular liver function testsAntiretroviral medication taken together with TB treatment may have side effects and interactions requiring careful monitoringTreatment can last for 6-12 months so some patients may drop out and need assertive outreach approaches to re-engage A vaccine is available
TUBERCULOSIS
Slide27HIV: Antiretroviral treatment is successful; no vaccine is available Acute bacterial infections: Staphylococcus and streptococcus can be treated with identification of source and antibiotics
Sexually transmitted infections all associated with long term morbidity if left untreatedChlamydia and gonorrhoea: antibiotics but some strains are resistantSyphylis: penicillin is preferred treatment; early treatment is crucialGenital herpes: antiviral medication; no cure; can flare up
HIV, ACUTE BACTERIAL INFECTIONS
Slide28Specialist advice should be sought from e.g. sexually transmitted disease clinic (STD), specialist chest clinic
The GP and services should liaise regularly to ensure screening and effective treatmentSpecialists working in primary care, chest clinics and STD services should contact specialist addiction services to arrange access and management of substance problemsREFERRAL, NETWORKS AND SERVICES
Slide29If patients are reluctant to stop or reduce their drug use, preventative measures should be discussed and implemented to contain infection risks and spreadAdvice on safer injecting, use of sterile equipment , and risks of diseases should be given
If patients continue to inject, clean needles and syringes should be obtainedPrevention of BBV has many benefits including reducing health harms by those who use substancesHINTS &TIPS
Slide30Needle and syringe programmesComprehensive protocols to raise awareness of risks of BBV: promotion of testing, deliver vaccination and access pathways into treatment
Provision of advice and materials to reduce harm from injecting drug useOffers of testing and vaccination to all those at riskPrevention of uptake of injecting drug use and promote switching from injecting to other routesImplementation of workforce and occupational health interventions for people working with those at risk of contracting BBV
PREVENTION
Slide31Findings (2014) Drug Matrix cell D1: Organisational functioning; Reducing harm
http://findings.org.uk/count/downloads/download.php?file=Matrix%2FDrugs%2FD1.htmHealth Protection Agency (2015) Hepatitis C in the UK. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/448710/NEW_FINAL_HCV_2015_IN_THE_UK_REPORT_28072015_v2.pdf
Health Protection Agency (2014) Shooting Up Infections among injecting drug users in the UK 2013. An update: November 2014 https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/370707/Shooting_Up_2014.pdfHealth Protection Agency (2013) Substance misuse and TB: Information for key workers (care workers, social workers, project workers and health professionals) https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/466947/NKS_Substance_misuse_and_TB_Information_for_key_workers_.
pdfJones D. R. et al, (2004) Prevalence, severity, and co-occurrence of chronic physical health problems of persons with serious mental illness. Psychiatric Services, 55 pp1250-1257National Knowledge Service - TB: http://www.neli.org.uk/IntegratedCRD.nsf/e67b3914fbe8da658025755c0062cd62/45aa03ceba2bc98080257145003ace45?OpenDocument&Highlight=0,TB
NICE
(2004) Hepatitis C - pegylated interferons, ribavirin and alfa interferon (NICE technology appraisal,TA75)
http://
guidance.nice.org.uk/TA75
This
guidance replaces Hepatitis C - alpha interferon and ribavirin (TA14). This guidance is extended by Hepatitis C -
peginterferon
alfa and ribavirin (TA106).
http://
guidance.nice.org.uk/TA75
References
Slide32NICE (2014) Needle and syringe programmes: NICE public health guidance 52 guidance. http://www.nice.org.uk/guidance/ph52
NICE (2006) Hepatitis B (chronic) - adefovir dipivoxil and pegylated interferon alpha-2a (NICE technology appraisal,TA96) http://guidance.nice.org.uk/TA96
NICE (2010) Hepatitis C - peginterferon alfa and ribavirin (NICE technology appraisal,TA200) http://guidance.nice.org.uk/TA200Public Health England (2015) Hepatitis C in the UK: 2015 report. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/448710/NEW_FINAL_HCV_2015_IN_THE_UK_REPORT_28072015_v2.pdf Public Health England:
https://www.gov.uk/topic/health-protection/infectious-diseasesRaoult D., Foucalt, C., Brouqui P.(2001) Infections in the homeless. The Lancet Infectious Diseases Vol 1(2) September pp77-84Tetrault, J M,
Fiellin
, D A, and Sullivan L E (2010) Substance Abuse and HIV:
Treatment Challenges
Substance Abuse and HIV: Treatment. The AIDS Reader. August 13, pp1-8
Wiessing
, L.,
Ferri
, M., Grady, B.,
Kantzanou
, M.,
Sperle
, I., Cullen, K.,
Hatzakis
, A.,
Prins
, M., Vickerman, P., Lazarus, J.V., Hope, V.,
Matheï
, C. (2014) ‘Hepatitis C virus infection epidemiology among people who inject drugs in Europe – A systematic review of data for scaling up treatment and prevention’,
PLoS
ONE 9(7): e103345. doi:10.1371/journal.pone.0103345
World Hepatitis Alliance
http://www.worldhepatitisalliance.org
/
References